I often get referrals from the town’s free clinic.  As you would imagine, the patients often have a unique set of problems, coming as they do from the underserved segment of society.

One such patient, Julia, was a fiftyish-year-old woman who had recently moved to town from California. She went to the free clinic (not really sure what the original complaint was) and ended up getting a physical exam that revealed a breast mass, which precipitated a mammogram, and then a biopsy, and a breast cancer diagnosis.

She started right off explaining to me that she had moved away from California to our little town, not because there was family close by (as I would only later find out) but because there was a conspiracy in California where she had been persecuted, where there were people trying to allege that she was crazy.  This conspiracy, she went on to explain, went high up in the government, and even involved Governor Schwarzenegger.

Wow.  OK, then.

I asked if she felt her move had been a good choice, and how she was doing, and she said she felt she had gotten away from the bad people, and life was better now.  Great.

We went on then to talk about breast cancer, about lumpectomy versus mastectomy, about radiation therapy, about chemotherapy, how all those elements are chosen for any given patient.  What was interesting to me was how despite her obvious compromise in thought processes, she was lucid and focussed on the topic of breast cancer.  She wanted a lumpectomy.  She understood she would need radiation therapy.  She asked reasonable questions and made reasonable choices with regard to her breast cancer treatment.

On the day of her surgery, she was forced into bringing someone to give her a ride home, and on this occasion I had a chance to meet her family.   She had given me permission to speak with them post-operatively, and it was then that they disclosed that she was a paranoid schizophrenic who refused to accept her diagnosis, and refused to take any medications.  They were doing what they could to help her, but she lived out of the back of her car, and they worried she might again flee if they tried to get her psychiatric help.

She kept her post-operative appointment, and then went on to complete radiation therapy.  She saw a medical oncologist, who recommended chemotherapy, which she refused.

All this was some years ago, and I still see her from time to time at the local grocery. She says hello, tells me no sign of the cancer, a big grin on her face (“I beat cancer!”) and thanks me for taking care of her.

Mental illness is such a tough problem.  From a medical standpoint, it’s an organ dysfunction like any other, but we know so very little really, about the way the human mind works.  And it really governs everything, doesn’t it?  Everything we do, everything we feel, every choice we make, how we interact with others.  It is frightening to think about people around us who perhaps do not have capacity to understand societal restrictions, of what we consider right and wrong.

In reality, the actual occurrence of this dangerous variety of mental illness is quite rare.  Sure, we hear about it in the news, some patient shooting some doctor in his office, disgruntled over something, though it seems more often there is political or ideological motivation behind the homicide, as, for example, over the issue of abortion.  Very occasionally, we hear of a mentally ill pilot who intentionally crashes a plane full of people.  You don’t see anybody giving up plane travel, though.

There are some things in the world you just can’t fix.  But there are others you definitely can.  The wisdom is in knowing the difference.

“Hope Amantine” is a surgeon who blogs at Simple Country Surgeon.